WikiMSK:Featured Journal Article/1 July 2025
Managing radicular pain in patients with normal MRIs: Challenges and insights?
David A. Provenzano, Julie Pilitsis, Christine Hunt. Interventional Pain Medicine. June 2025
ABSTRACT - This article discusses the management of lumbar radicular pain in patients with normal or near-normal MRIs. They note that while epidural steroid injections are common for radicular pain with clear MRI abnormalities, their effectiveness is questionable when such findings are absent. The authors highlight a Cohen et al. study, which found that ESIs offered limited benefits for patients with normal imaging, showing that a higher percentage of patients with abnormal imaging experienced positive outcomes at four weeks. The commentary suggests that for patients with radicular pain but normal MRIs, physicians should be discerning, as the likelihood of success with ESIs is low. A thorough clinical evaluation is emphasized to rule out other potential causes of pain, and alternative diagnostic tools like EMG/NCS may be useful. Ultimately, the authors concur with the study's implication that a comprehensive assessment is crucial before considering ESIs in this specific patient population.
EDITOR'S COMMENT - In New Zealand, it's not uncommon for radiology reports to only comment on surgically relevant but not necessarily all clinically relevant abnormalities of the spine. Some radiologists may only note the presence or absence of compression within the central canal and foramina. For diagnosing pain, however, nerve contact without obvious compression is also significant, and we must assess four key sites: the central canal, lateral recess, foramen, and the far lateral zone. It is imperative for clinicians to personally review all MRI scans they order, effectively providing a "double read." This practice becomes especially important in situations of clinical mismatch. It is also important to provide feedback to the radiologists so that they are aware what abnormalities we are interested in.
